BILL ANALYSIS Ó AB 2216 Page 1 Date of Hearing: April 12, 2016 ASSEMBLY COMMITTEE ON HEALTH Jim Wood, Chair AB 2216 (Bonta) - As Amended March 28, 2016 SUBJECT: Primary care residency programs: grant program. SUMMARY: Establishes the Teaching Health Center (THC) Primary Care Graduate Medical Education Fund for purposes of funding primary care residency programs. Specifically, this bill: 1)Establishes the Teaching Health Center Primary Care Graduate Medical Education Fund (Fund) in the State Treasury. 2)Requires the Director of the Office of Statewide Health Planning and Development (OSHPD) to award planning and development grants from the Fund to teaching health centers for the purpose of establishing new accredited or expanded primary care residency programs. 3)Provides that grants awarded must not be for more than three years and that the maximum award to a teaching health center must not be more than five hundred thousand dollars ($500,000). 4)Specifies that grants be used to cover the costs of AB 2216 Page 2 establishing or expanding a primary care residency training program, including costs associated with curriculum development, recruitment, training, and retention of residents and faculty, accreditation by the Accreditation Council for Graduate Medical Education (ACGME), the American Dental Association (ADA), or the American Osteopathic Association (AOA), faculty salaries during the development phase, and technical assistance. 5)Requires OSHPD, subject to an appropriation by the Legislature, to award sustaining grants from the Fund to THCs operating primary care residency programs accredited by the ACGME, ADA, or AOA, and requires OSPHD to determine the amount of grants awarded per resident by taking into account the direct and indirect costs of graduate medical education. EXISTING LAW: 1)Establishes OSHPD to, among other functions, collect data and disseminate information about California's health care infrastructure, promote equitable distribution of health care outcomes, and publish information about health care outcomes. 2)Establishes the California Healthcare Workforce Policy Commission (Commission) and requires the Commission to, among other things, identify specific areas of the state where unmet priority needs for primary care family physicians and registered nurses exist; establish standards for family practice training programs, family practice residency programs, primary care physician assistants programs, and programs that train primary care nurse practitioners; and, review and make recommendations to OSHPD concerning the funding of those programs that are submitted to the Health Professions Development Program for participation in the state medical contract program. AB 2216 Page 3 3)Establishes the Health Professions Education Foundation (HPEF) within OSHPD. Requires the HPEF to solicit and receive funds from foundations and other private and public sources and to provide financial assistance in the form of scholarships or loans to students in the health professions who are from underrepresented groups. Provides that HPEF governed by a board consisting of 13 members appointed by the Governor, Speaker of the Assembly, and Senate Rules Committee. 4)Establishes, under the HPEF, scholarship, loan, and loan repayment programs for registered nurses, vocational nurses, geriatric nurse practitioners, clinical nurse specialists, and mental health professionals who agree to practice for specified periods of time in underserved areas and in designated practice settings. 5)Establishes, under HPEF, the Steven M. Thompson Physician Corps Loan Repayment Program (STPCLRP), which provides for the repayment of educational loans for licensed physicians and surgeons who practice in medically underserved areas of the state. Requires HPEF, in administering the STPCLRP, to use and develop guidelines for applicants that give preference to applicants who are best suited to meet the cultural and linguistic needs of patients in medically underserved populations, as specified, and who agree to practice in geriatric care settings. Also allows HPEF to appoint a selection committee to provide policy direction and guidance to the STPCLRP. Requires funds for loan repayment under the STPCLRP to have a funding match from a foundation or other private source. Establishes a Medically Underserved Account for Physicians within the Fund, the primary purpose of which AB 2216 Page 4 is to provide funding for the STPCLRP. 6)Establishes within OSHPD the Health Professions Education Fund to receive funds for scholarships and loans to students from underrepresented groups who are enrolled in or accepted to schools of medicine, dentistry, nursing, and other health professions. Provides that moneys in the fund are continuously appropriated. 7)Establishes the Song-Brown Health Care Workforce Training Act of 1973 (Song-Brown Act), administered by OSHPD to provide financial support to family practice residency programs, nurse practitioner and physician assistant programs, and registered nurse education programs to increase the number of students and residents receiving education and training in family practice and nursing. The Song-Brown Act also encourages universities and primary care health professionals to provide health care in medically underserved areas. FISCAL EFFECT: This bill has not been analyzed by a fiscal committee. COMMENTS: 1)PURPOSE OF THIS BILL. According to the author THCs are a proven model for addressing the primary care provider shortage that six of nine California regions face. The author notes that 40% of THC graduates entering into primary care practice in nonprofit, community health centers in underserved communities as opposed to just 4% of traditional medical residents. The author concludes that this bill will help ensure California has a sufficient supply of health workforce AB 2216 Page 5 professionals to serve the needs of our diverse state. 2)BACKGROUND. a) Primary Care in California. California is home to the largest number of primary care physicians and nurse practitioners in the country. However, the state ranks 23rd in the number of primary care physicians per resident. An August 2014 report by the California HealthCare Foundation states that California has only 35 to 49 primary care physicians per 100,000 Medi-Cal enrollees. Federal guidelines call for the state to have 60 to 80 doctors per 100,000 patients. The supply of primary care physicians also varies substantially across California's counties. The number of primary care physicians actively practicing in California counties is, in too many cases, at the bottom range of, or below, the state's need. According to 2011 Health Resources and Services Administration (HRSA) data, 29 of California's 58 counties fall at the lower end, or below, the needed supply range for primary care physicians. In other words, half of Californians live in a community where they do not have adequate access to the health care services they need. b) The Teaching Health Center Graduate Medical Education (THCGME) program. THCGME, funded since 2011 and set to expire in 2015, has increased the numbers of primary care physicians and dentists training to care for underserved populations nationwide. Without continued federal funding, most of these THCs report that they would be unlikely to continue current residency recruitment and enrollment, threatening the initial program investments and even the viability of the program itself. AB 2216 Page 6 According to a 2015 Robert Graham Center report, "Teaching Health Center GME Funding Instability Threatens Program Viability," residents who train in underserved settings are more likely to continue to practice in similar environments. The THCGME program supports new and expanded community-based primary care training programs. Organizations that can qualify to be THCs include federally qualified health centers, rural health clinics, and tribal clinics-all organizations that care for the underserved. Unlike most other GME payments, funds flow directly to the community-based, ambulatory patient care centers where residents train, instead of teaching hospitals. The investment of $230 million over five years (2011 to 2015) represents 0.3% of the annual $15 billion federal GME funding that supports more than 120,000 residents in training each year nationwide. THCGME will expire in 2015 if there is no congressional action to extend it. Since their creation under the Patient Protection and Affordable Care Act (ACA) six THCs have opened in California, however they are in danger of closing due to the uncertain funding. They are located in Modesto, Fresno, San Bernardino, Redding, Bakersfield, and San Diego. Nationally, the majority of THCGME supported programs are just beginning to have their first graduating classes. The first grants did not start in California until fiscal year 2011 for Academic Year 2011-2012. Primary care residencies are three years long. According to a California Primary Care Association (CPCA) AB 2216 Page 7 January 2015 report, "Horizon 2030," preliminary results from the national study demonstrate positive and promising results for THCGME. Most notably: i) Almost all (91%) of THC graduates remain in primary care practice, compared to less than one-quarter (23%) of traditional GME graduates; ii) About three times as many THC graduates (76%) choose to practice in underserved communities, compared to 26% of traditional graduates; iii) Almost four times (21%) as many THC graduates enter practice in rural areas, versus 5% of traditional graduates; iv) Forty percent (40%) of THC graduates go on to practice at Community Clinic Health Centers, compared to 2% of traditional graduates; and, v) Most (66%) of the initial THC graduates continue to practice in the states where they were residents. 3)SUPPORT. CPCA is the sponsor of this bill and states that this bill will help address California's primary care provider shortage by establishing the Fund, providing planning and development grants to THCs for the purpose of establishing new accredited or expanded primary care residency programs, and make available sustaining grants to ensure the continued AB 2216 Page 8 operation of accredited THCs. CPCA estimates that 8,243 additional primary care physicians will be needed in California by 2030, and notes that with dwindling federal support for current THC sites and no federal investment to develop new sites, California must prioritize and demonstrate its commitment to providing access to primary care through a greater investment in the THC model. The County Health Executives Association of California and the California School Employees Association support this bill, noting that, since the passage of the ACA, the workforce of primary care physicians in California has not kept pace, especially with increasing enrollment in Medi-Cal, and this bill will assist in meeting the need for physicians to serve the growing number of newly insured and Medi-Cal patients. The Association of California Healthcare Districts (ACHD) states, healthcare districts located in rural and remote areas of the state have a difficult time recruiting health professionals to their areas. ACHD notes that THCs are on the leading edge of innovation educational programming dedicated to ensuring a relevant and sufficient supply of health workforce professionals, however due to limited and uncertain federal funding the six programs in California are in jeopardy of closing. ACHD concludes that this bill will support the expansion of primary care residency programs in California. 4)OPPOSITION. The California Right to Life Committee, Inc. opposes this bill stating that because the definition of a California Primary Care Residency Program includes obstetrics and gynecology, they are assuming that Title X and family planning education will be included in the medical education for the residency program. 5)RELATED LEGISLATION. AB 2216 Page 9 a) AB 2048 (Gray) requires OSHPD, in its administration of the National Health Service Corps State Loan Repayment Program (SLRP), to include all federally qualified health centers (FQHCs) located in California on the program's certified eligible site list. AB 2048 is currently pending in the Assembly Appropriations Committee. b) SB 22 (Roth) appropriate $300 million from the General Fund to the director of OSHPD for the purpose of funding new and existing GME physician residency positions, and supporting training faculty. SB 22 is currently pending in the Assembly Rules Committee. 6)PREVIOUS LEGISLATION. a) SB 1416 (Rubio) of 2012 would have created the Graduate Medical Education Trust Fund for the purpose of funding grants to graduate medical education residency programs in California, and would have required OSHPD to develop criteria for distribution of available moneys. SB 1416 was held in the Assembly Appropriations Committee b) AB 589 (Perea), Chapter 339, Statutes of 2012, establishes the Steven M. Thompson Medical School Scholarship Program and would provide that the program is open to persons who agree in writing, prior to entering an accredited medical or osteopathic school, to serve in an eligible practice setting, as defined, for at least three years. AB 2216 Page 10 c) SB 635 (EHernandez) of 2011 would have required funds deposited in the Managed Care Administrative Fines and Penalties Fund in excess of $1 million be transferred each year to OSHPD for the purposes of the Song-Brown Program. SB 635 was held in the Assembly Appropriations Committee. d) TECHNICAL AMENDMENT. As currently drafted this bill requires OSHPD to award sustaining grants from the Fund to THCs operating primary care residency programs accredited by the ACGME, ADA, or AOA, and requires OSPHD to determine the amount of grants awarded per resident by taking into account the direct and indirect costs of graduate medical education, but does not define what a "sustaining grant" is. This bill should be amended as follows: On page 3, between lines 31 and 32 insert: (c) For purposes of this section, "sustaining grant" means a grant awarded to ensure the continued operation of an accredited teaching health center, whether that accreditation is first awarded pursuant to the process created by this article or the accreditation is awarded prior to enactment of this article. REGISTERED SUPPORT / OPPOSITION: Support California Primary Care Association (sponsor) Alameda Health Consortium AB 2216 Page 11 AltaMed Health Services Corporation Ampla Health Association of California Healthcare Districts Community Clinic Association of Los Angeles County California School Employees Association Clinica Sierra Vista Community Clinic Consortium Community Health Center Network County Health Executives Association of California Family Health Centers of San Diego Health Alliance of Northern California Health and Life Organization, Inc. Kheir Center AB 2216 Page 12 Marin Community Clinics Mountain Valleys Health Centers North Coast Clinics Network North County Health Services North East Medical Services Omni Family Health Open Door Community Health Centers Ravenswood Family Health Center Redwood Community Health Coalition San Ysidro Health Center St. John's Well Child & Family Center Tiburcio Vasquez Health Center, Inc. Valley Community Healthcare AB 2216 Page 13 Western Sierra Medical Clinic White Memorial Community Health Center Opposition California Right to Life Committee, Inc. Analysis Prepared by:Lara Flynn / HEALTH / (916) 319-2097